The accuracy required to do an Anatomic ACL Reconstruction is critical to a positive outcome for the patient. While tunnel location is certainly very important in an ACL Reconstruction, using the correct fixation device is also paramount. Bryce Bederka, MD of the Legacy Orthopedics and Sports Medicine Group in Portland, OR recently collaborated with the Smith & Nephew Endoscopy InVentures team to pioneer a new device that ensures a precise and reproducible method for determining tunnel depth and fixation length. The very responsive InVentures design team worked closely with Dr. Bederka - in fact, he was using the product in his operating room less than three months from initial contact. Joint Intelligence chatted with Dr. Bederka about the thought process behind the device and how to most effectively use it during Anatomic ACL Reconstruction procedures.

JI: What is your typical ACL reconstruction technique?
BB: I utilize a medial portal technique which I converted to soon after starting practice.  I was never completely satisfied with the restrictions on tunnel placement by a trans-tibial technique, and was intrigued by the details arising with the new anatomic approaches.  I have since been using a single bundle anatomic medial portal technique with good success.

JI: Why did you decide to collaborate with Smith & Nephew on the ENDOBUTTON◊ INDICATOR Selection Device and what was the process?
BB: I have used the ENDOBUTTON◊ Fixation Device for femoral fixation, and so working with Smith & Nephew was a logical choice. I worked with the Smith & Nephew InVentures team on the initial product development phase. I appreciated the collaborative interplay between myself and the engineers throughout the stages of initial product design and testing.  We have been through three prototype stages and testing to bring the ENDOBUTTON◊ Indicator Selection Device to its now fourth design and on to the rollout and commercialization phase.

JI: What was the driving need behind the development of the ENDOBUTTON◊ INDICATOR Selection Device?
BB: For my purposes, the measurement techniques for the ENDOBUTTON◊ CL Fixation Device were unsatisfactory. I felt the current techniques were too time consuming. I prefer less guesswork regarding depth as I breach the cortex.  With the precision needed for the short femoral tunnel with an anatomic technique, a better solution was needed.

Initially, a simple depth gauge was all that was envisioned, but it became readily apparent that a more elegant and functional device could be constructed.  One of the limitations of the new user to the ENDOBUTTON◊ CL Fixation Device is the calculations as to what length tunnel to drill, and what length ENDOBUTTON◊ CL Fixation Device to implant.  The ENDOBUTTON◊ INDICATOR Selection Device provides the solutions to both of these issues.  The ENDOBUTTON◊ INDICATOR Selection Device takes on the role of many devices to simplify the surgical technique, acting as a depth gauge, calculating the lengths of the socket to drill, determining which lengths of ENDOBUTTON◊ CL Fixation Device are appropriate depending on desired interference in the socket, and finally as a pin puller for the beath pin.

JI: How has the device simplified your ACL reconstruction technique using ENDOBUTTON◊ CL Fixation Device?
BB: The ENDOBUTTON◊ INDICATOR Selection Device has combined many steps into one by serving as a pin puller, specifying the tunnel length, and recommending the depth of the femoral socket and which length ENDOBUTTON◊ CL Fixation Device to use. It is useful for transitioning to the shorter tunnels necessitated with anatomic ACL reconstruction.

The ENDOBUTTON◊ INDICATOR Selection Device is also very useable with the CLANCY Flexible Drill System.  Utilizing a specially designed calibrated flexible beath pin, it is simply the most effective way to determine the tunnel depth and ENDOBUTTON◊ CL Fixation Device size with the CLANCY Flexible Drill System.

JI: What are the key pearls and pitfalls in using the device?
BB: The ENDOBUTTON◊ INDICATOR Selection Device must be used with a calibrated and marked beath pin, either rigid or flexible depending on which reamer system the surgeon is using.  The pin is driven into the bone of the femoral notch to the stop mark.  A nick is made in the skin along the pin on the lateral thigh with a #15 scalpel blade, and the ENDOBUTTON◊ INDICATOR Selection Device is placed over the pin.  Your scrub will need to make sure that the set screws are loose and that the pin passes smoothly through the ENDOBUTTON◊ INDICATOR Selection Device before you use it.

The measurements are read through the windows on the device.  If there is a range of size options, select the size which gives as much graft in the femoral tunnel as possible.  Convention recommends 20mm of graft in the tunnel, but I have significant experience with short tunnels that allow as little as 15mm of graft in the tunnel (with a 15mm loop) and have not had problems with graft incorporation or reconstruction failure while using standard rehabilitation techniques.  If a tunnel measurement is considered too short, then an ENDOBUTTON◊ Direct Fixation Device may be utilized instead.

Lock down both set screws before drawing the beath pin and passing suture through the knee.  I would strongly recommend that the beath pin be left in the ENDOBUTTON◊ INDICATOR Selection Device until the end of the procedure in the event that measurements need to be re-checked.

Utilizing a medial portal technique, I measure and drill the femoral tunnel first.  With the tunnel distance and ENDOBUTTON◊ CL Fixation Device size determined before any tunnels are drilled, my assistant has the time to prepare the graft while I drill the femoral and then tibial tunnels.  This saves time that would be spent waiting for the graft to be prepared over the ENDOBUTTON◊ CL Fixation Device and marked for implantation. Then, when the tunnel drilling is completed, the prepared graft is on the correct ENDOBUTTON◊ Fixation Device and is ready for immediate implantation.